General Flight Authorization, Release of Liability, and Indemnity Form

All forms must be completed-in-full by the patient with the exception of the Physician’s Release which must be completed by the patient’s physician and submitted before a flight can be considered.

As with any mode of transportation, certain risks are present. You should also know that the same regulatory standards that apply to commercial charter or airline flights are not required to be followed by the volunteer pilot conducting your flight. Specific questions about how your flight will be conducted should be addressed to the volunteer pilot for the flight.

Patient or Supporting Passenger Note: Complete, Sign, and Fax both pages to LifeLine Pilots. You must complete all blanks and sign this Agreement if you will be a passenger (patient or support) on a LifeLine Pilots flight, or you are a parent, guardian or other legally authorized person able to consent to a flight for a minor and/or supporting passenger (hereinafter referred to as a “Minor”) or an adult patient unable to provide his/her own consent (hereinafter referred to as an “Other Individual.”) By signing this Agreement, you agree that in exchange for this free air transportation, you, the Minor and/or Other Individual, if applicable, are giving up any rights to recover damages in the event of your and/or the Minor’s/Other Individual’s death, injury, property loss or any other loss arising from an accident, incident, cancellation or delay in connection with any such flights.

I, on behalf of myself and the Minor(s)/Other Individual(s), if applicable, acknowledge that:

Lifeline, Inc. dba LifeLine Pilots (hereinafter referred to as LLP), and other assisting Volunteer Pilot Organizations, facilitate access to free air transportation through FAA-certified volunteer pilots who have offered their assistance to fly me and/or to the referenced Minor/Other Individual. LifeLine Pilots does not provide aircraft nor does it control the conduct of the flight. The Volunteer Pilot and aircraft owners are solely responsible for the conduct of the flight and for the aircraft provided.

By signing this Release Agreement, I understand that the services donated on my behalf, in the form of time, services, aircraft, and flight expenses being furnished by the Pilot, Co-Pilot, and aircraft owner constitute a significant value and material personal benefit in exchange for this release. I regard such transportation as a significant material factor in my well-being and physical prosperity and, if applicable, that of the Minor/Other Individual that is the passenger for whom the flight is being conducted and for whom I am consenting;

LifeLine Pilots and its volunteer Pilot(s) and aircraft owner(s), relying on this general release, may provide air transportation to assist passenger(s) on one or more occasions to obtain and/or return from prescribed medical treatment/evaluation or other medically related purposes;

As a non-commercial, non-profit volunteer organization, volunteer pilots and aircraft owners will not be financially reimbursed for their services or the expenses of this flight by either LifeLine Pilots nor patients/passengers served. The volunteer Pilots will provide the pilot services and aircraft for the air transportation described above, free of charge, at the request of and for the assistance of the patient and any supporting persons identified below;

The accomplishment of the objective of the flight is not guaranteed;

These flights are flown by the Pilot alone. No crew assistance is provided. Passengers are personally responsible for entering and exiting the aircraft without assistance from the Pilot. The passengers are responsible for providing their own support or assistance. The Pilot may be unable to provide assistance to passengers in exiting the aircraft in the event of an emergency. If additional assistance is needed, the passenger is responsible for providing his/her own personal assistant, and advance arrangements must be made with LifeLine Pilots Mission Coordinators.

All patients/passengers are responsible for their own ground transportation, room and board arrangements and expenses, both scheduled and unplanned, in the event of a flight delay or cancellation.

In consideration for receiving aircraft and Pilot services provided free of charge, I personally and on behalf of the Minor/Other Individual, if applicable, agree with respect to each such flight:

While in or about the aircraft, to assume all risk of damage or injury, including death, however caused, as well as the risk that the objective of a flight may not be accomplished;

That neither I, the Minor/Other Individual, or any of my/their heirs, representatives or assigns will make any claim or bring any cause of action against LifeLine Pilots, the Pilot(s) and aircraft owner(s) as a result of any personal injury, wrongful death, property damage or other loss or damage occurring while in or about the aircraft or in connection with the flight, irrespective of cause. I/they hereby release and hold harmless LifeLine, Inc. dba LifeLine Pilots, the Pilot(s) and the aircraft owners(s) from any such claims or suits.

To protect and hold harmless, undertake the defense of, and fully indemnify LifeLine Pilots; their members, directors, officers, employees and volunteers; the volunteer Pilot(s); the aircraft owner(s); and their heirs, assigns, and successors in interest from all loss, liability, damages, fees, costs, and expenses of defense of any suit brought by any party relating to the intended transportation, including cancellation or delay of a flight or the failure to provide a return flight, irrespective of cause.

I, on behalf of myself and the Minors/Other Individual(s), if applicable, do hereby grant permission to LifeLine Pilots to use my/our name and visual image in any marketing publications which might appear in the various media, or in connection with public relations activities of LifeLine Pilots.

I hereby confirm that I have carefully read and understand this agreement, that it is a Release of potential claims of liability for the negligence of LifeLine Pilots, the Pilot(s), aircraft owner(s), or other volunteers by me on behalf of myself and any Minor/Other Individual unable to provide his/her own consent) for whom I am responsible, and that I am signing it of my own free will.

IMPORTANT NOTE: Anyone on the flight who is also consenting for a Minor/Other Person, will need to sign in two (2) places below, both as the parent, legal Guardian (sole or shared), or other capacity.

1st Adult Patient/Passenger (18 years or older) on behalf of myself:

Name*

FirstLast

Date*

Date Format: MM slash DD slash YYYY

Signature*

Address*

Street AddressAddress Line 2CityStateZIP Code

Emergency Contact*

FirstLast

Emergency Contact Phone*

2nd Adult Passenger?

Yes

2nd Adult Passenger, (18 years or older) on behalf of myself (if applicable)

Name*

FirstLast

Date*

Date Format: MM slash DD slash YYYY

Signature*

Address*

Street AddressAddress Line 2CityStateZIP Code

Emergency Contact*

FirstLast

Emergency Contact Phone*

Parent, Legal Guardian or other Person Authorized to Sign for Minor/Other Individual(s) below

Yes

Parent, Legal Guardian or other Person Authorized to Sign for Minor/Other Individual(s) below (Proof of guardianship may be required):

Name*

FirstLast

Date*

Date Format: MM slash DD slash YYYY

Signature*

Nature of Relationship

Parent

Sole Guardianship

Shared Guardianship

Shared Guardianship With:

Emergency Contact*

FirstLast

Emergency Contact Phone*

Minor (less than 18 years old/Other Individual) or other individual unable to give consent

FirstLast

Address

Street AddressAddress Line 2CityStateZIP Code

Emergency Contact*

FirstLast

Emergency Contact Phone*

Second Minor?

Yes

Second Minor Details

Minor (less than 18 years old/Other Individual) or other individual unable to give consent